Trauma is a major risk factor for the development of a venous thromboembolism (VTE). After observing higher than expected VTE rates within our center's Trauma Quality Improvement Program data, we instituted a change in our VTE prophylaxis protocol, moving to enoxaparin dosing titrated by anti-Xa levels. We hypothesized that this intervention would lower our symptomatic VTE rates.Adult trauma patients at a single institution meeting National Trauma Data Standard criteria from April 2015 to September 2019 were examined with regards to VTE chemoprophylaxis regimen and VTE incidence. Two groups of patients were identified based on VTE protocol-those who received enoxaparin 30 mg twice daily without routine anti-Xa levels ("pre") versus those who received enoxaparin 40 mg twice daily with dose titrated by serial anti-Xa levels ("post"). Univariate and multivariate analyses were performed to define statistically significant differences in VTE incidence between the two cohorts.There were 1698 patients within the "pre" group and 1406 patients within the "post" group. The two groups were essentially the same in terms of demographics and risk factors for bleeding or thrombosis. There was a statistically significant reduction in VTE rate (p = 0.01) and deep vein thrombosis rate (p = 0.01) but no significant reduction in pulmonary embolism rate (p = 0.21) after implementation of the anti-Xa titration protocol. Risk-adjusted Trauma Quality Improvement Program data showed an improvement in rate of symptomatic pulmonary embolism from fifth decile to first decile.A protocol titrating prophylactic enoxaparin dose based on anti-Xa levels reduced VTE rates. Implementation of this type of protocol requires diligence from the physician and pharmacist team. Further research will investigate the impact of protocol compliance and time to appropriate anti-Xa level on incidence of VTE.Therapeutic/care management, Level IV.
Trauma recidivists are a high-risk patient population. The effects of recidivism on Geriatric trauma mortality have not been investigated. Our hypothesis is that trauma recidivism is associated with high postdischarge mortality after the initial index admission in both the geriatric and adult trauma populations. The trauma registry of our Level I trauma center was queried for patients evaluated between 2008 and 2012. Patients were stratified adult (18-64) and geriatric (≥65) groups and matched with mortality data from the National Death Index. Unique patients were identified and recidivists flagged. Statistical analysis was performed based on characteristics from the index admission using nonparametric tests, and Kaplan-Meier curves were plotted to examine postdischarge mortality after index admission for recidivists. A total of 8716 records met inclusion criteria; 800 recidivist records were identified representing 369 unique patients. Recidivists presented between 2 and 7 times. Recidivists were more likely to be male, required ICU admission and mechanical ventilation, had a longer median length of stay, were less likely to discharge home, and had a higher postdischarge mortality. Stratifying into adult and geriatric groups demonstrated significant differences in injury severity, injury patterns, length of stay, race, gender, mechanism, and postdischarge mortality. Recidivists demonstrated a higher postdischarge mortality in both groups with the geriatric group approaching 46 per cent. Trauma recidivists represent an at-risk group with significantly higher postdischarge mortality. Group characteristics differ significantly between the adult and geriatric recidivist populations. Further research is needed to identify modifiable risk factors in these populations to minimize risks of morbidity and mortality.
Geriatric trauma patients with low-level falls often have multiple comorbidities and limited physiologic reserve. Our aim was to investigate postdischarge mortality in this population. We hypothesized that five-year mortality would be higher relative to other blunt mechanisms. The registry of our Level 1 trauma center was queried for patients evaluated between July 2008 and December 2012. Adult patients identified were matched with mortality data from 2008 to 2013 from the National Death Index. Low-level falls were identified by E Codes; other types of blunt trauma were based on registry classification. Patients with multiple admissions were excluded. Univariate analysis was performed using Fisher's exact and Wilcoxon tests. Kaplan-Meier curves were plotted to compare postdischarge mortality. Seven thousand nine hundred sixteen patients were evaluated, 35.1 per cent were females. Patients aged less than 65 years and penetrating trauma were excluded, yielding 1997 patients—63.7 per cent with low-level falls versus 36.3 per cent with other blunt traumas. Geriatric patients sustaining low-level falls were older, more likely female, had a higher inpatient mortality, and were less likely to return home at discharge. Injury severity score, hospital length of stay, and intensive care unit length of stay were similar. Survival analysis demonstrated increased postdischarge mortality in the low-level fall group with 25 per cent mortality at 120 days. Geriatric patients with other blunt trauma had a significantly lower postdischarge mortality. Geriatric patients injured in low-level falls have a higher inhospital mortality, are more likely to be functionally dependent on discharge, and have a high post-discharge mortality. Opportunities likely exist for injury prevention, consideration of palliative care, and postdischarge rehabilitation.
Hospital-acquired infections (HAI) in trauma patients increase inpatient morbidity and mortality. However, their impact on long-term mortality is not well understood.A retrospective trauma registry analysis of all patients admitted to an academic level I trauma center between July 1, 2008 and December 31, 2012 was performed. Patients included survived to discharge and were 18 years of age or older. Age, gender, Injury Severity Score (ISS), ventilator use, history of chronic obstructive pulmonary disease (COPD), and HAI were reviewed. Name, social security number, and date of birth were used to extract National Death Index data from 2008-2013 for an outcome of mortality after discharge, time to death, and cause of death. Unadjusted logistic regression was performed. Multiple logistic regression was used to adjust for patient and injury characteristics and to determine odds of mortality in the post-discharge period.A total of 8,275 patients met inclusion criteria; 65.4% were male and the median age was 47. The mean ISS was 11 ± 8.9. Nine hundred seventeen patients (11.1%) died after discharge; 4.8% of patients had hospital-acquired pneumonia (HAP) and 4.2% had a urinary tract infection (UTI). The unadjusted odds ratio (OR) of mortality after discharge in patients who had pneumonia and UTI were 1.77 (1.35, 2.31, p < 0.001) and 2.44 (1.87, 3.17, p < 0.001), respectively. After adjusting for patient age, gender, ISS, ventilator use, and history of COPD (pneumonia patients only), the odds for mortality after discharge remained significant for pneumonia (OR = 1.57 (1.09, 2.23), p = 0.013) but not for UTI (OR = 1.25 (0.93, 1.68), p = 0.147). The top causes of death after discharge in patients with HAP were COPD (11.4%) and falls (7.1%).Trauma patients with HAP have higher mortality after hospital discharge. Prevention strategies for HAP including pulmonary toilet, early mobility, pain control, and early extubation must be a priority. Unfortunately, patients who develop pneumonia may have a decreased reserve, or ability to recover from their traumatic injuries and HAI. Further characterization of HAP and its subsequent treatment strategies are needed.
BACKGROUND This study aims to compare and externally validate the previously developed Revised Intensity Battle Score (RIBS) against other proposed scores for predicting poor outcomes after rib fractures. METHODS An external validation set was assembled retrospectively, comprising 1,493 adult patients with one or more rib fractures admitted to a Level 1 trauma center between 2019 and 2022. The following rib fracture scores were calculated for each patient: RIBS, Injury Severity Score, Rib Fracture Score, Chest Trauma Score, and Battle score. Each was investigated to assess utility in predicting mortality, intensive care unit upgrade, unplanned intubation and ventilator days. Performance was measured by area under the receiver operating characteristic curve. RESULTS Of the 1,493 patients who met inclusion criteria, 239 patients (16%) experienced one of more of the investigated outcomes. Generally, scores performed best at predicting mortality and ventilator days. The RIBS stood out as best predicting “any complication” (AUC = 0.735) and “>7 ventilator days” (AUC = 0.771). CONCLUSION The RIBS represents an externally validated triage score in patients with rib fractures and compares favorably to other static scoring systems. Use of this score as a triage tool may allow stratifying patients who may benefit from direct intensive care unit admission, neuraxial anesthesia and aggressive respiratory care. Next steps include prospective investigation of how pairing these interventions with score directed triage impacts outcomes LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
We investigated the patterns of injury associated with major midface trauma. Our hypothesis is that midface injuries are associated with a decrease in certain traumatic brain injuries as well as major torso injuries. The registry of our Level I trauma center was queried for all adult patients treated over 25 years from 1989 to 2013. Patients with midface fractures were identified based on the ICD-9 code. Associated injuries were defined based both on individual ICD-9 codes as well as the Barell Injury Matrix. Injury etiology was defined based on e-codes. Univariate analysis was performed using chi-squared test, Fisher's exact test, and Wilcoxon test. A total of 29,152 patients were identified. Excluding pediatric patients, those with exclusively penetrating trauma, and patients with incomplete data, 20,971 patients were included for subsequent analysis. Midface fractures were identified in 752 patients. Patients with Le Fort fractures were more likely to be male, have a higher Injury Severity Score, a lower arrival Glasgow Coma Scale, and more likely to require intensive care unit admission and mechanical ventilation, with a longer hospital length of stay. Patients with midface fractures had significantly fewer subdural hematomas, subarachnoid hemorrhages, spine fractures, and were less likely to have associated abdominal and pelvic injuries. Patients with midface fractures were more likely to require facial reconstruction procedures and craniotomy. Patients presenting with midface fractures after blunt trauma have a distinctly different pattern of injuries. One potential mechanism for this is a deceleration effect, where midface impact and resulting fractures dissipate some of the energy.
